Financing a healthy civilisation
Authors: None The Lancet Planetary Health
Journal: The Lancet Planetary Health (2019)

In January this year, The Lancet Planetary Health called for research pertaining to all of the Sustainable Development Goals (SDGs). Now, with publication in The Lancet of a comprehensive guide to the state of global health financing, a clearer picture emerges of the perilous state of the health of the poorest members of our civilisation. Whether their countries' health systems can be funded and improved—in an environmentally sustainable way—is the looming challenge to the global community's ability to reach the SDGs that aim to end poverty, reduce inequality, and promote health for all. Between 1995 and 2016, per capita health spending grew by 2·7% per year worldwide to US$8·0 trillion overall, but in low-income countries (home to 732 million people) the yearly spend per person increased only 1·5%, from $30 in 1995 to $40 in 2016. In 22 countries, health spending rose by less than a dollar per person in the 20 years to 2016. Substantial improvements to health cannot occur with such a dearth of funding. The greatest contribution to increases in health financing in low-income countries came from development assistance for health (DAH), chiefly money from the US and other states' governments and private philanthropy. DAH is one of the great political and philanthropic endeavours of our time. However, appetite for DAH is politically volatile, the extent to which it displaces governmental spending on health (fungibility) is unclear, and issues surround accountability and priority setting. Moreover, if global development aid is diverted to combat climate change, health funding will suffer despite existing synergies. Growth in DAH in absolute terms has plateaued and is predicted to rise only slowly to 2050. Ultimately, any resilient health system will need to be able to operate in the absence of external donor funding. Poverty is not restricted to low-income nations, with most (73%) of the world's poor living in middle-income countries. DAH only comprises a small segment of total health spend in middle-income countries (0·2–3·2% in 2016). Nevertheless, these countries still received 57% of global DAH in 2016, suggesting substantial inequality, and that a hidden poor will be missing from high-level assessment of the SDGs if a country-level approach is taken. Measurement of the SDG targets ought to take account of unsustainable or unstable funding sources. In the health financing transition model, countries start with a low level of health spending, principally out of pocket, then transition to increased spending through government financing. In the short term, low-income countries will continue to rely on out-of-pocket payments and donor funding. In the longer term, strategies are needed that increase government investment and levels of prepaid resources to avoid individuals experiencing catastrophic health expenditure. How though, can low-income countries' governments prioritise health spending (the key driver of increased government spending, alongside overall economic development)? The decision to prioritise health is not in of itself an endpoint. Parkinson's law—the adage that work expands so as to fill any and all available time—is equally true of health-care costs. As income rises, countries can spend more on health but value may diminish. Research into sustainable approaches to end poverty and break the impasse in health funding in low-income countries is essential to the notion of planetary health. In particular, what advances could be made via leapfrogging (eg, skipping expensive development phases) or use of tried and tested approaches to resource allocation (eg, favouring strong primary care and disease prevention)? Is redistribution of DAH from middle-income countries to low-income countries viable or desirable? To what extent is fungibility a threat to government health spending? And at the individual level, how can the challenge of increasing out-of-pocket and other private spending (eg, health insurance or direct service payment by companies) be addressed? Low-income countries have been unable to realise the gains in health spending seen in middle-income countries over the past 20 years. While development assistance for health increased per person from $3 in 1995 to $10 in 2016, overall spending rose by just $10. If seven out of every ten extra dollars spent on health in low-income countries is DAH, it is clear that future developments need to take a different track. Governments also need development assistance to raise more and spend more money on health; a civilisation cannot be considered truly healthy while nearly a billion people are adrift.